Postoperative complications, including infections at a surgical site and other distant nosocomial infections in high risk patients, are estimated to be between 25% and 30%. Patients particularly prone to postoperative infections are those who are malnourished prior to surgery, the elderly, and those about to undergo major gastrointestinal and non-cardiac thoracic procedures.
As early as 1987, perioperative use of parenteral nutrition was recommended by the Health and Public Policy Committee of the American College of Physicians for severely malnourished patients having major surgery, such as intra-abdominal or non-cardiac intrathoracic surgery (Health and Public Policy Committee, American College of Physicians, "perioperative parenteral Nutrition", Ann. Int. Med., 107:252-253 (1987)). Unselected use of total parenteral nutrition (TPN) is not justified, especially in mild or moderately malnourished patients because its use has been shown to be associated with an increased rate of infections and non-infectious complications (Detsky et al., "Perioperative Parenteral Nutrition: A Meta-Analysis", Ann. Int. Med., 187;107:195-203) . Around the same time, Klein and others (Klein et al., "Total Parenteral Nutrition and Cancer Clinical Trials", Cancer, 58:1378-1386 (1986).) reviewed the existing literature on cancer patients and found that the TPN is not useful if used routinely in all patients with cancer. However, they found that its preoperative use in cancer patients with gastrointestinal disease may help reduce major surgical complications and improve survival, treatment toxicity, and tumor response in patients receiving chemotherapy or radiation therapy.
Recently, thirty-three, high quality, randomized, prospective studies were reviewed on the subject of pre- and post-operative feeding, including 2,500 patients (Klein et al., "Nutritional Support in Clinical Practice: Review of Published data and recommendations for Future Research Directions", J. Parent. Ent. Nutr., 21: 133-156 (1997)). There were 13 studies including 1,250 patients who received preoperative TPN for 7 to 10 days. Most of the studies (9/13) found that patients, who received TPN and were moderately malnourished based on weight loss or depressed serum protein concentrations, had fewer postoperative complications. Those receiving preoperative TPN had 10% fewer complications and no change in mortality rates compared to those who were not preoperatively fed. There were two studies where enteral nutrition was used preoperatively for 10 days in cancer patients and postoperative complications were reduced (12%).